1. APPLICANT INFORMATION
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- Elwin Stevens
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1 GARAGE APPLICATION Acceptance Indemnity Insurance Company Acceptance Casualty Insurance Company Occidental Fire & Casualty Company of rth Carolina Wilshire Insurance Company Please answer ALL questions. Incomplete or missing answers may cause processing delays or decline of coverage. Requested policy period: Effective Date: Expiration Date: 1. APPLICANT INFORMATION a. Form of business: Individual Corporation Partnership Joint Venture Other: b. Applicant/Named Insured: (DBA): c. Mailing Address: d. Garage Locations: Loc# Address City State Zip Lot Protection 1 Building Standard nstandard 2 Building Standard nstandard 3 Building Standard nstandard Building: Separate property supplemental application required. Standard Open Lot: Open parking storage lots enclosed on all sides by a metal cyclone or equivalent fence not less than six feet height or bounded on one or more sides by the wall or walls of a building, with no unprotected openings, and with the exposedsides of lot enclosed by a metal cyclone or equivalent fence no less than six feet in height, with openings securely locked when unattended. e. Years in business: Years experience in this industry: Years ownership/management experience: f. Provide complete details of all prior work experience: g. Phone: Inspection Contact: h. Website Address: i. What are your days and hours of operation? j. Describe your business operations? k. Are you engaged in any other operations? l. Do you conduct operations or have driving exposures in any state(s) other than where your garage operation is domiciled? If yes, explain, including which state(s): 2. PRIOR CARRIER / LOSS INFORMATION a. During the past three (3) years, has any company ever cancelled, declined or refused to issue any similar insurance to the applicant? b. Prior carriers for the last three (3) years. If no prior insurance, state NONE. Carrier Name Policy Period Premium Year 1 to $ Year 2 to $ Year 3 to $ AG Page 1 of 7
2 c. Prior loss information: Date of Loss Description of Loss Amount Amount Paid Reserved 3. GENERAL UNDERWRITING INFORMATION a. Do you loan, lease or rent vehicles to others? b. Do you engage in any rideshare programs? c. Do you own or sponsor a race car? d. Do you repossess: (1) Autos that you have sold? (2) Autos for others? e. Any salvage/auto dismantling operations? If yes, separate supplemental application required. f. Any animals kept on the premises? If yes, what breed(s) and purpose?: g. Provide maximum radius for pickup and delivery: (1) Owned Autos: miles. (2) n-owned/customer s Autos: miles. How many times per month? h. How many plates do you have: Dealer: Transport/Transit: Other: (1) Where are plates stored when not in use? (2) Do you loan or rent plates? i. Describe your key control procedures: (1) During business hours: (2) After business hours: j. Are firearms kept on the premises? k. Do you utilize sub-contractors? If yes: (1) Who and for what purpose?: (2) Are certificates of insurance obtained from all? l. Do you attend or host trade shows, fairs, or any other special events? m. Percentage of operation ( X all applicable operations below and show % of sales and/or % repair for each) Type of Autos Sales % Repair % ATVs, Snowmobiles* Boats, Jet Skis or Other Watercraft Buses: Type: Passenger Capacity: Contractors/Construction Equipment* Emergency Vehicles: Police Fire Ambulance Farm Equipment Golf Carts Motorcycles, Scooters* Motor Homes, Recreational Vehicles, Campers* Private Passenger (including pickups, mini vans or SUVs) Trailers: Semi-Trailers Utility Trailers Fifth Wheels Livestock Trucks and/or Truck Tractors (other than pickups, mini vans or SUVs)* Other (describe): *Separate supplemental application required AG Page 2 of 7
3 4. DEALER INFORMATION X if no dealer operations exists a. Are you a licensed dealer? Dealer ID #: n-franchised Franchised with Type: Retail % Wholesale % Broker % Auction* % *If Auction applies, separate supplemental application must be completed. b. Do you sell on consignment? (If yes, copy of agreement required) If yes: On your lot At other dealership locations c. Estimate number of vehicles sold per year: d. Do you engage in Internet Sales? If yes: (1) Who is responsible for title transfer? e. Test drives: (2) How are vehicles transported? (1) Do you allow customers to test drive vehicles unaccompanied? (2) Do you obtain a copy of their Driver License? (3) Do you obtain a copy of their proof of insurance? (4) Do you allow overnight test drives? f. Which of the following are used to transport or drive away vehicles from the places where they are purchased: Employees Contract Drivers Transport Carrier Other: g. Where do you purchase vehicles (provide %)? Other dealers Auction Other h. When are titles transferred? At time of sale When auto is paid in full Other: i. Do you require personal auto insurance to be in place prior to relinquishing a sold vehicle? j. If you finance for sale (Buy-here/Pay-here operation), are you listed as a lienholder? k. Value of owned (inventory) Loc# Average value Maximum value Average # of Maximum # of Maximum value of all AG Page 3 of 7
4 5. NON-DEALER INFORMATION X if no service/non-dealer operations exists Must equal 100% Service/Repair Airbags Alarm/Stereo Installation Auto Parts New: % Used: % Uninstalled % Body Brakes Breathalyzers/Ignition Interlock Devices Car Wash Attended Unattended/Self-Serve Detail Shop Drive-away contractors Engine Frame Cutting Welding Stretching Straightening Hydraulic Lifting apparatuses Describe: LPG (Liquefied Petroleum Gas) Oil/Lube Painting U/L approved booth n-u/l approved booth* Parking Facility: Public Valet** Performance Enhancements (Beyond original manufacturer specs) Service/Convenience Store** Gas Grocery Liquor Storage/Impound Lot Suspension Lift Kits Height: Tires: New % Used % Recaps, Re-Treads, Split Rim Work Trailer Hitch Installation Bolt-On Weld-On Upholstery Windshield Installation/Tinting General Maintenance & Repair Other (describe): **Separate supplemental application required a. Where are operations performed? (provide % for each that apply) Your premises Customer Premises Roadside Other: Percentage b. Do you modify, rebuild or perform conversions on vehicles? c. Do you weld? (1) What do you weld? (2) What protective safeguards are in place to prevent fire? d. Are signs posted to keep customers from work areas? e. Do you manufacture or fabricate or auto parts? f. Do you offer expedited service (example: 30 min or less - quick lube)? g. Value of non-owned (customer) Loc# Average value Maximum value Average # of Maximum # of Maximum value of all AG Page 4 of 7
5 6. OWNERS, EMPLOYEES AND DRIVERS INFORMATION a. List all owners, employees, drivers and household members of driving age (ALL employees, whether they drive or not & ALL household members, whether involved in garage operations or not): First & Last Name Driver s License Number / State Accidents & Violations (within the past 5 years) Furnished (Personal use) Status* Hours DOB (1 11) Worked** / / / / / / / / / / / Personal Auto Policy / Excluded Driver Do you utilize unscheduled (contract) drivers? If yes: 1. Do you verify each has a valid US driver s license? 2. How many times per month? *Status: 6 Mechanic 1 Active Owner, Partner or Officer 7 Clerical 2 Inactive Owner, Partner or Officer 8 Scheduled Driver 3 Salesperson 9 Spouse of Owner, Partner or Officer 4 Manager 10 Child of Owner, Partner or Officer (whether licensed to drive or not) 5 Lot Person 11 Other: **Hours Worked: F Full Time (over 20 hours per week) P Part Time (20 hours or less per week) N n-employee / b. Have all individuals with access to use a covered auto been listed on this application If no, explain: AG Page 5 of 7
6 7. COVERAGE REQUESTED Provide limits and deductibles for all requested coverages: COVERAGE LIMITS DEDUCTIBLES Each Accident Aggregate $ PD Garage Liability (Auto & Other Than Auto) (Other Than Auto only) $ BI & PD $ 1x 2x 3x Personal Injury Protection Uninsured Motorists Underinsured Motorists Medical Payments Auto & Premises Premises Only $ $ $ Errors & Omissions Odometer Truth in Lending Title Garagekeepers Legal Direct Excess Direct Primary Fire/Theft Per Location Per Auto Specified Causes Loc 1 $ Comprehensive Loc 2 $ Loc 3 $ Dealers Physical Damage Per Location Per Auto Fire/Theft Loc 1 $ Specified Causes Loc 2 $ Comprehensive Loc 3 $ False Pretense $ Broadened Coverage Personal Injury Liability Damage to Rented Premises $ Employment Practices Additional Insured Name: Address: Insurable Interest: Optional Coverages not listed: Landlord Waiver of Subrogation Other: Service vehicles, including tow trucks, car haulers and wreckers or specifically described : Are filings required? If yes, list MC # and/or Certificate #: Year Make Model VIN/Serial # MGVW Use Radius In-Tow 1 $ Liability PIP UM/UIM Med Pay (Limits follow policy coverages) Physical Damage -Limit: $ Deductible: $ 2 $ Liability PIP UM/UIM Med Pay (Limits follow policy coverages) Physical Damage -Limit: $ Deductible: $ 3 $ Liability PIP UM/UIM Med Pay (Limits follow policy coverages) Physical Damage -Limit: $ Deductible: $ AG Page 6 of 7
7 The Applicant, Agent and/or Broker represents that the above statements and facts are true and that no material facts have been suppressed or misstated. Completion of this form does not bind coverage or commit the Company to policy issuance. NOTICE TO APPLICANTS (EXCEPT CO & NY): Any person who knowingly makes a claim containing false information or intentionally misrepresents any material fact or knowingly presents false or misleading information in an application for insurance may be guilty of a crime and subject to criminal and civil penalties. NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Applicant Name Applicant Signature Date Producer Name Producer Signature Date Producer Phone Number Producer Street Address AG Page 7 of 7
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